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ObjectivesA subset of laryngeal squamous cell carcinoma (LSCC) patients undergoing larynx preserving treatment ultimately require total laryngectomy (TL) for oncologic or functional reasons. This study aims to identify TL risk factors in these patients.MethodsRetrospective cohort study using Veterans Affairs (VA) database. T1-T4 LSCC cases treated with primary radiotherapy (XRT) or chemoradiotherapy (CRT) were assessed for TL and recurrence. Binary logistic and Cox regression and Kaplan-Meier analyses were implemented.ResultsOf 5390 cases, 863 (16.0%) underwent TL. On multivariable analysis, age (adjusted odds ratio: 0.97 [0.96-0.98]; p T1 disease (T2, 1.76 [1.44-2.17]; p

BACKGROUND: Diagnostic codes can be instrumental for case identification in Alzheimers disease (AD) research; however, this method has known limitations and cannot distinguish between disease stages. Clinical notes may offer more detailed information including AD severity and can complement diagnostic codes for case identification. OBJECTIVE: To estimate prevalence of mild cognitive impairment (MCI) and AD using diagnostics codes and clinical notes available in the electronic healthcare record (EHR). METHODS: This was a retrospective study in the Veterans Affairs Healthcare System (VAHS). Health records from Veterans aged 65 years or older were reviewed during Fiscal Years (FY) 2010-2019. Overall, 274,736 and 469,569 Veterans were identified based on a rule-based algorithm as having at least one clinical note for MCI and AD, respectively; 201,211 and 149,779 Veterans had a diagnostic code for MCI and AD, respectively. During FY 2011-2018, likely MCI or AD diagnosis was defined by≥2 qualifiers (i.e., notes and/or codes)≥30 days apart. Veterans with only 1 qualifier were considered as suspected MCI/AD. RESULTS: Over the 8-year study, 147,106 and 207,225 Veterans had likely MCI and AD, respectively. From 2011 to 2018, yearly MCI prevalence increased from 0.9% to 2.2%; yearly AD prevalence slightly decreased from 2.4% to 2.1%; mild AD changed from 22.9% to 26.8%, moderate AD changed from 26.5% to 29.1%, and severe AD changed from 24.6% to 30.7. CONCLUSIONS: The relative distribution of AD severities was stable over time. Accurate prevalence estimation is critical for healthcare resource allocation and facilitating patients receiving innovative medicines.

Objectives: The reasons for and incidence of delay in screening colonoscopies during the coronavirus disease 2019 (COVID-19) pandemic are of major public health interest. The risks and reasons for delay likely vary between public and private institutions. This research sought to analyze data regarding the completion of screening colonoscopies after a positive fecal immunochemical test (FIT) before and during the COVID-19 pandemic and the reasons for a delay in obtaining these results at the Lt. Col. Luke Weathers, Jr. Veterans Affairs Medical Center. The goals were to evaluate the institutional resilience and analyze the problems associated with this major healthcare crisis. Methods: This closed cohort study included all positive FITs from our local Veterans Affairs (VA) medical center from October 2019 to January 2020 and July 2020 to May 2021. A total of 115 VA patients with a positive FIT prepandemic and 157 VA patients with a positive FIT during the pandemic were included. Completion rates within 180 days were measured, and charts were reviewed to identify the reasons for lack of completion. Both community and local VA procedures for veterans were included. Univariate and multivariable analyses were applied to calculate odds ratios (ORs). The Pearson χ² test was applied to calculate P values. Results: VA patients' percentage of timely completion was lower pre-COVID-19 than it was during the pandemic, and the percentage of delayed completion was higher pre-COVID-19 than it was during the pandemic. Comparing patients who completed a colonoscopy with those who did not, increasing age had an OR of 0.947 (95% CI 0.920-0.975), and White race had an OR of 0.504 (95% CI 0.291-0.873). Evaluating delays in colonoscopy completion, VA colonoscopies versus referral to the community had an OR of 4.472 (95% CI 1.602-12.483), and pre-COVID-19 completion versus during COVID-19 had an OR of 4.663 (95% CI 1.727-12.594) with multivariable logistic regression. Conclusions: There was a statistically significant increase in timely colonoscopy completion during the study period when compared with the pre-COVID-19 period. The completion rate was higher at the Lt. Col. Luke Weathers, Jr. VA Medical Center than a large population average in 2020, possibly related to community colonoscopies and an aggressive case management system. In addition, increasing age and White race were associated with decreased colonoscopy completion. Predictors of an increased delay in colonoscopy completion included a pre-COVID-19 positive FIT and colonoscopies performed within the VA rather than being referred to providers in the community. A common reason for delay in all of the groups was patients declining intervention and delay/lack of referral. [ABSTRACT FROM AUTHOR]

The purpose of this study was to develop and validate an algorithm for identifying Veterans with a history of traumatic brain injury (TBI) in the Veterans Affairs (VA) electronic health record using VA Million Veteran Program (MVP) data. Manual chart review (n = 200) was first used to establish 'gold standard' diagnosis labels for TBI ('Yes TBI' vs. 'No TBI'). To develop our algorithm, we used PheCAP, a semi-supervised pipeline that relied on the chart review diagnosis labels to train and create a prediction model for TBI. Cross-validation was used to train and evaluate the proposed algorithm, 'TBI-PheCAP.' TBI-PheCAP performance was compared to existing TBI algorithms and phenotyping methods, and the final algorithm was run on all MVP participants (n = 702,740) to assign a predicted probability for TBI and a binary classification status choosing specificity = 90%. The TBI-PheCAP algorithm had an area under the receiver operating characteristic curve of 0.92, sensitivity of 84%, and positive predictive value (PPV) of 98% at specificity = 90%. TBI-PheCAP generally performed better than other classification methods, with equivalent or higher sensitivity and PPV than existing rules-based TBI algorithms and MVP TBI-related survey data. Given its strong classification metrics, the TBI-PheCAP algorithm is recommended for use in future population-based TBI research. [ABSTRACT FROM AUTHOR]

Background: Identifying patient‐, facility‐, and environment‐level factors that influence the initiation and retention of comprehensive lifestyle management interventions (CLMI) for urban and rural Veterans could improve obesity treatment and reach at Veterans Affairs (VA) facilities. Aims: This study identified factors at these various levels that predicted treatment engagement, retention, and weight management among urban and rural Veterans. Methods: A retrospective cohort study of 631,325 Veterans was designed using VA databases to identify Veterans with class II and III obesity during 2015–2017. Primary outcomes were initiation of CLMI, bariatric surgery, or obesity pharmacotherapy within 1 year of index date. Secondary outcomes included treatment retention and successful weight loss. Generalized linear mixed models were used to evaluate the relationships between factors and obesity‐related outcomes, with rurality differences assessed through interaction terms. Results: Patient characteristics associated with increased odds of initiating CLMI included female sex (p < 0.001), black race (p < 0.001), sleep apnea (p < 0.001), mood disorder (p < 0.001), and use of medications associated with weight loss (p < 0.001) or weight gain (p < 0.001). Facility use of telehealth was associated with greater odds of CLMI initiation in urban Veterans (p < 0.001) but lower retention in both populations (p = 0.003). Routine consideration of pharmacotherapy was associated with higher CLMI initiation. Environmental characteristics associated with increased odds of CLMI initiation included percent of population foreign born (OR = 1.03 per 10% increase; p < 0.001), percent black (p < 0.001), and high walkability index (p < 0.001). The relationship between total population and CLMI initiation differed by rurality, as greater population was associated with lower odds of CLMI initiation in urban areas (OR: 0.99 per 1000 population; p < 0.001), but higher odds in rural areas (OR:1.01, p = 0.01). Veterans in the south were less likely to initiate CLMI and had lower retention (p < 0.001). Conclusion: Treatment and retention of CLMI among Veterans remain low, highlighting areas for improvement to expand its reach both urban and rural Veterans. [ABSTRACT FROM AUTHOR]

BackgroundThe burden of heart failure is growing. Guideline-directed medical therapies (GDMT) reduce adverse outcomes in heart failure with reduced ejection fraction (HFrEF). Whether there is geographic variation in HFrEF quality of care is not well described.ObjectivesThis study evaluated variation nationally for prescription of GDMT within the Veterans Health Administration.MethodsA cohort of Veterans with HFrEF had their address linked to hospital referral regions (HRRs). GDMT prescription was defined using pharmacy data between July 1, 2020, and July 1, 2021. Within HRRs, we calculated the percentage of Veterans prescribed GDMT and a composite GDMT z-score. National choropleth maps were created to evaluate prescription variation. Associations between GDMT performance and demographic characteristics were evaluated using linear regression.ResultsMaps demonstrated significant variation in the HRR composite score and GDMT prescriptions. Within HRRs, the prescription of beta-blockers to Veterans was highest with a median of 80% (IQR: 77.3%-82.2%) followed by angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitors (69.3%; IQR: 66.4%-72.1%), sodium-glucose cotransporter 2 inhibitors (10.3%; IQR: 7.7%-12.8%), mineralocorticoid receptor antagonists (29.2%; IQR: 25.8%-33.9%), and angiotensin receptor-neprilysin inhibitors (12.2%; IQR: 8.6%-15.3%). HRR composite GDMT z-scores were inversely associated with the HRR median Gini coefficient (R = -0.13; P = 0.0218) and the percentage of low-income residents (R = -0.117; P = 0.0413).ConclusionsWide geographic differences exist for HFrEF care. Targeted strategies may be required to increase GDMT prescription for Veterans in lower-performing regions, including those affected by income inequality and poverty.

Abstract Background Early detection through screening dramatically improves lung cancer survival rates, including among war Veterans, who are at heightened risk. The effectiveness of low dose computed tomography scans in lung cancer screening (LCS) prompted the Veteran’s Affairs Lung Precision Oncology Program (VA LPOP) to increase screening rates. We aimed to develop an adaptive population health tool to determine adequate resource allocation for the program, with a specific focus on primary care providers, nurse navigators, and radiologists. Methods We developed a tool using C + + that uses inputs that represents the process of the VA LCS program in Ann Arbor, Michigan to calculate FTEs of human resource needs to screen a given population. Further, we performed a sensitivity analysis to understand how resource needs are impacted by changes in population, screening eligibility, and time allocated for the nurse navigators’ tasks. Results Using estimates from the VA LCS Program as demonstrative inputs, we determined that the greatest number of full-time equivalents required were for radiologists, followed by nurse navigators and then primary care providers, for a target population of 75,000. An increase in the population resulted in a linear increase of resource needs, with radiologists experiencing the greatest rate of increase, followed by nurse navigators and primary care providers. These resource requirements changed with primary care providers, nurse navigators and radiologists demonstrating the greatest increase when 1–20, 20–40 and > 40% of Veterans accepted to be screened respectively. Finally, when increasing the time allocated to check eligibility by the nurse navigator from zero to three minutes, there was a linear increase in the full-time equivalents required for the nurse navigator. Conclusion Variation of resource utilization demonstrated by our user facing tool emphasizes the importance of tailored strategies to accommodate specific population demographics and downstream work. We will continue to refine this tool by incorporating additional variability in system parameters, resource requirements following an abnormal test result, and resource distribution over time to reach steady state. While our tool is designed for a specific program in one center, it has wider applicability to other cancer screening programs.

Matthew E Sprong,1,2 Heaven Hollender,3 Bob Blankenberger,2 Stuart Rumrill,4 Yu-Sheng Lee,5 Travis Bland,2 Jeremiah Bailey,6 Kenneth Weber,1 James Gilbert,1 Ken Kriz,2 Frank D Buono7 1Edward Hines Jr. VA Medical Center, Hines, IL, USA; 2University of Illinois Springfield, School of Public Management and Policy, Springfield, IL, USA; 3Indiana University - Indianapolis, School of Health & Human Services, Indianapolis, IN, USA; 4Univerity of Illinois Urbana-Champaign, Department of Kinesiology and Community Health, Champaign, IL, USA; 5University of Illinois Springfield, School of Integrated Sciences, Sustainability, and Public Health, Springfield, IL, USA; 6Florida Agricultural and Mechanical University, Department of Sociology and Criminal Justice, Tallahassee, FL, USA; 7Yale School of Medicine, New Haven, CT, USACorrespondence: Matthew E Sprong, Email mspro2@uis.eduIntroduction: Veterans diagnosed with mental health and/or substance use disorders (SUD) often face significant barriers to employment and reintegration into civilian society. In the current study, we investigated whether how the VA healthcare system for mental health and/or SUD treatment predicted program enrollment into vocational rehabilitation, simultaneous mental health and/or SUD treatment while enrolled in vocational rehabilitation predicted employment at discharge, and mental health and/or SUD treatment continues and employment remain 60-days-post-vocational-rehabilitation discharge.Methods: An outcome-based, summative program evaluation design to measure quality assurance of vocational rehabilitation services provided to 402 veteran patients enrolled in a VA healthcare located within the Great Lakes Health Care System – Veterans Integrated Services Network.Results: Multivariable logistic regression analyses showed psychological empowerment (confidence in one’s ability to work or find work) is a significant factor determining whether a veteran is enrolled in the vocational rehabilitation program, prior mental health treatment (yes/no) and frequency of mental health treatment did not predict program enrollment, and frequency of SUD VA system treatment 60 days prior did not predict program enrollment. Other findings showed that simultaneous mental health and/or SUD treatment while enrolled in vocational rehabilitation did not predict employment at discharge, and employment at discharge did not predict continued mental health and/or SUD treatment post-discharge from vocational rehabilitation. However, veterans with both SUD and mental health and continued mental health treatment were less likely to be employed.Conclusion: Utilization of real-world program evaluation data from an actual VHA vocational rehabilitation program enhances the study’s ecological validity, offering practical implications for policymakers and practitioners in the field. The findings support the importance of veterans enrolling in mental health and/or SUD treatment simultaneously while enrolled in vocational rehabilitation services, as integrating vocational rehabilitation with mental health and SUD treatment services can lead to improved vocational and health outcomes for veterans (eg, development of targeted interventions to support veterans’ successful reintegration into the workforce and society).Keywords: substance use disorders, mental health, veterans affairs, health administration, veterans, vocational rehabilitation, treatment access

BACKGROUND: Current methods to identify cardiovascular implantable electronic device lead failure include postapproval studies, which may be limited in scope, participant numbers, and attrition; studies relying on administrative codes, which lack specificity; and voluntary adverse event reporting, which cannot determine incidence or attribution to the lead. OBJECTIVE: The purpose of this study was to determine whether adjudicated remote monitoring (RM) data can address these limitations and augment lead safety evaluation. METHODS: Among 48,191 actively monitored patients with a cardiovascular implantable electronic device, we identified RM transmissions signifying incident lead abnormalities and, separately, identified all leads abandoned or extracted between April 1, 2019, and April 1, 2021. We queried electronic health record and Medicare fee-for-service claims data to determine whether patients had administrative codes for lead failure. We verified lead failure through manual electronic health record review. RESULTS: Of the 48,191 patients, 1170 (2.4%) had incident lead abnormalities detected by RM. Of these, 409 patients had administrative codes for lead failure, and 233 of these 409 patients (57.0%) had structural lead failure verified through chart review. Of the 761 patients without administrative codes, 167 (21.9%) had structural lead failure verified through chart review. Thus, 400 patients with RM transmissions suggestive of lead abnormalities (34.2%) had structural lead failure. In addition, 200 patients without preceding abnormal RM transmissions had leads abandoned or extracted for structural failure, making the total lead failure cohort 600 patients (66.7% with RM abnormalities, 33.3% without). Patients with isolated right atrial or left ventricular lead failure were less likely to have lead replacement and administrative codes reflective of lead failure. CONCLUSION: RM may strengthen real-world assessment of lead failure, particularly for leads where patients do not undergo replacement.

Background: Early detection through screening dramatically improves lung cancer survival rates, including among war Veterans, who are at heightened risk. The effectiveness of low dose computed tomography scans in lung cancer screening (LCS) prompted the Veteran's Affairs Lung Precision Oncology Program (VA LPOP) to increase screening rates. We aimed to develop an adaptive population health tool to determine adequate resource allocation for the program, with a specific focus on primary care providers, nurse navigators, and radiologists. Methods: We developed a tool using C + + that uses inputs that represents the process of the VA LCS program in Ann Arbor, Michigan to calculate FTEs of human resource needs to screen a given population. Further, we performed a sensitivity analysis to understand how resource needs are impacted by changes in population, screening eligibility, and time allocated for the nurse navigators' tasks. Results: Using estimates from the VA LCS Program as demonstrative inputs, we determined that the greatest number of full-time equivalents required were for radiologists, followed by nurse navigators and then primary care providers, for a target population of 75,000. An increase in the population resulted in a linear increase of resource needs, with radiologists experiencing the greatest rate of increase, followed by nurse navigators and primary care providers. These resource requirements changed with primary care providers, nurse navigators and radiologists demonstrating the greatest increase when 1–20, 20–40 and > 40% of Veterans accepted to be screened respectively. Finally, when increasing the time allocated to check eligibility by the nurse navigator from zero to three minutes, there was a linear increase in the full-time equivalents required for the nurse navigator. Conclusion: Variation of resource utilization demonstrated by our user facing tool emphasizes the importance of tailored strategies to accommodate specific population demographics and downstream work. We will continue to refine this tool by incorporating additional variability in system parameters, resource requirements following an abnormal test result, and resource distribution over time to reach steady state. While our tool is designed for a specific program in one center, it has wider applicability to other cancer screening programs. [ABSTRACT FROM AUTHOR]

Background Given the negative consequences associated with a penicillin allergy label, broader penicillin allergy delabeling initiatives are highly desirable but hindered by the shortage of allergists in the United States. To address this problem at our facility, the infectious diseases section introduced a quality improvement initiative to evaluate and remove allergy labels among inpatient veterans. Methods Between 15 November 2022 and 15 December 2023, we identified inpatients with a penicillin allergy label. We subsequently interviewed eligible candidates to stratify penicillin allergy risk and attempt to remove the allergy label directly via chart review, following inpatient oral amoxicillin challenge or outpatient community care allergy referral. Delabeling outcomes, subsequent penicillin-class prescriptions, and relabeling were tracked after successful allergy label removal. Results We screened 272 veterans, of whom 154 were interviewed for this intervention. A total of 53 patients were delabeled: 26 directly, 23 following oral amoxicillin challenge, and 4 following outpatient allergy referrals. Of the patients who were delabeled, 25 received subsequent penicillin-class prescriptions. No adverse reactions occurred following inpatient oral amoxicillin challenges. Patients with a low-risk penicillin allergy history were more likely to undergo a challenge if admitted with an infectious diseases–related condition. Only 1 inappropriate relabeling event occurred during the study period, which was subsequently corrected. Conclusions An infectious diseases provider–led initiative resulted in penicillin allergy label removal in more than one third of inpatients evaluated using direct removal or oral amoxicillin challenge. Efforts focused on patients who had been admitted for infections were particularly successful. [ABSTRACT FROM AUTHOR]

Objectives: Concurrent care is a unique care delivery system that allows patients to receive disease modifying treatments and other supportive interventions while also receiving the traditional benefits of hospice care. The objectives of our observational study were to examine health care utilization, use of cancer-directed therapies and palliative interventions, and location of death in patients enrolled in concurrent care. Methods: 72 hematology-oncology patients at the Hines Veteran's Affairs Medical Center (VAMC) who enrolled in concurrent care from 12/2018-4/2021 were reviewed. Data were summarized with descriptive statistics including medians and percentages. Results: A minority of patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.9%), blood products (11.1%), or invasive pain procedures (4.2%). Patients also used fewer cancer-directed treatments as they approached end of life (24.4% within 30 days of death compared to 13.3% within 14 days of death). Most patients died at home (62.9%) or in inpatient hospice (12.9%) as opposed to the hospital (2.9%). Conclusions: A minority of concurrent care patients received cancer-directed therapies or additional types of health care interventions despite the option to do so. Cancer-directed treatment utilization also decreased as patients approached end of life. Patients enrolled in concurrent care were able to appreciate its benefits for longer, as the average length of stay on concurrent care was nearly 3 months. [ABSTRACT FROM AUTHOR]

Background: Incretin therapies, comprised of the dipeptidyl peptidase-4 inhibitors (DPP-4i) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs), have been increasingly utilized for the treatment of type 2 diabetes (T2DM). Previous studies have conflicting results regarding risk of pancreatitis associated with these agents—some suggest an increased risk and others find no correlation. Adverse event reporting systems indicate that incretin therapies are some of the most common drugs associated with reports of pancreatitis. Objectives: This study aimed to compare the odds of developing pancreatitis in veterans with T2DM prescribed an incretin therapy versus thiazolidinediones (TZDs: pioglitazone and rosiglitazone) within the Veterans Health Administration (VHA). Methods: This was a retrospective cohort study analyzing veterans with T2DM first prescribed an incretin therapy or a TZD between January 1, 2011, and December 31, 2021. A diagnosis of pancreatitis within 365 days of being prescribed either therapy was counted as a positive case. Data was collected and analyzed utilizing VA's Informatics and Computing Infrastructure (VINCI) and an adjusted odds ratio was calculated. Results: The TZD cohort consisted of 42 912 patients compared with the incretin cohort of 304 811 patients. The TZD cohort had a pancreatitis incidence rate of 1.94 cases per 1000 patients. The incretin cohort had a incidence rate of 2.06 cases per 1000 patients. An adjusted odds ratio found no statistical difference of pancreatitis cases between the TZD and incretin cohorts (adjusted odds ratio [AOR] = 0.94, 95% CI [0.75, 1.18]). Conclusion and Relevance: This retrospective cohort study of national VHA data found a relatively low incidence of pancreatitis in both cohorts, and an adjusted odds ratio found no statistical difference of pancreatitis in patients prescribed an incretin therapy compared with a control group. This data adds to growing evidence that incretin therapies do not seem to be associated with an increased risk of developing pancreatitis. [ABSTRACT FROM AUTHOR]

Abstract Background Identifying patient‐, facility‐, and environment‐level factors that influence the initiation and retention of comprehensive lifestyle management interventions (CLMI) for urban and rural Veterans could improve obesity treatment and reach at Veterans Affairs (VA) facilities. Aims This study identified factors at these various levels that predicted treatment engagement, retention, and weight management among urban and rural Veterans. Methods A retrospective cohort study of 631,325 Veterans was designed using VA databases to identify Veterans with class II and III obesity during 2015–2017. Primary outcomes were initiation of CLMI, bariatric surgery, or obesity pharmacotherapy within 1 year of index date. Secondary outcomes included treatment retention and successful weight loss. Generalized linear mixed models were used to evaluate the relationships between factors and obesity‐related outcomes, with rurality differences assessed through interaction terms. Results Patient characteristics associated with increased odds of initiating CLMI included female sex (p

Background: Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site. Purpose: Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement. Methods: Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites. Results: Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care. Discussion and implications: Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended. [ABSTRACT FROM AUTHOR]

Objectives: This article describes the prevalence of preexisting gynecologic conditions associated with chronic pelvic pain (CPP) in veterans having hysterectomy for benign indications and explores whether preexisting CPP affects receipt of minimally invasive hysterectomy (MIH). Materials and Methods: This cross-sectional study used Veterans Health Administration (VHA) data to identify hysterectomies provided or paid for by the VHA between 2007 and 2014. Veterans were included if they had any type of hysterectomy—abdominal or MIH (vaginal, laparoscopic, or robotic). Veterans were categorized as having preexisting gynecologic conditions associated with CPP if they had an International Classification of Diseases, 9th Revision, Clinical Modification diagnosis of endometriosis/adenomyosis, dysmenorrhea, dyspareunia, or pelvic-congestion syndrome within 1 year prior to hysterectomy. Generalized linear models with a Poisson distribution were used to estimate the relative risks (RRs) and 95% confidence intervals (CIs) for preexisting CPP conditions and MIH. Results: The final sample had 6830 veterans who had hysterectomies. Of these, 66.5% (n = 4540) had preexisting CPP conditions. MIH was performed in 41.8% (n = 1897) of veterans who had preexisting CPP conditions. After adjustment, there was no association between preexisting CPP and MIH (unadjusted RR: 1.05; 95% CI: 0.97, 1.15; adjusted RR: 0.99; 95% CI: 0.90, 1.08). Conclusions: Veterans undergoing hysterectomy have a high prevalence of preexisting conditions associated with CPP. More hysterectomies were performed in veterans with preexisting CPP, compared to those without. However, the presence of preexisting CPP did not affect the likelihood of receiving MIH. (J GYNECOL SURG 40:149) [ABSTRACT FROM AUTHOR]

Overall, fewer Veterans were eligible for PrEP in 2020, compared to 2019, and 2018 (Maryland Veterans Affairs Health Care System- MVAHCS-: n = 890 (2020), n = 1533 (2019); Washington DC Veterans Affairs Medical Center -DC VAMC- n = 1119 (2020), n = 1716 (2019)). While the proportion of Veterans engaged in PrEP out of those eligible for PrEP increased in 2020 compared to 2019 at both sites (MVAHCS: 5.73% (2020) vs. 3.39% (2019) p-value = 0.006; F = 7.58, and DC VAMC: 15.91% (2020) vs. 9.38% (2019) p-value < 0.001; F = 27.64), the absolute number of Veterans engaged in PrEP remained unchanged (MVAHCS n = 51 (2020) and n = 52 (2019); DC VAMC n = 178 (2020) and n = 161 (2019)). Engagement in PrEP was significantly lower among Black Veterans compared to White Veterans at the DC VAMC across all FY with a widening gap in 2020. Cisgender women were less likely to be engaged in PrEP compared to cisgender men at both sites and throughout all FY with a wider gender gap in 2020. There were no significant differences in retention in PrEP between FY. Anticipated improvements in linkage, engagement, and retention in PrEP in 2020 at the MVAHCS and DC VAMC may not have been seen due to the COVID-19 pandemic. Furthermore, engagement rates in PrEP remained low overall, particularly among Black Veterans and cisgender women. Novel PrEP delivery models are needed to engage these populations in PrEP following the COVID-19 pandemic. Interactive dashboards and tele-PrEP may have played a big role in sustained retention in PrEP at the VHA. [ABSTRACT FROM AUTHOR]

Background Previous work has demonstrated disparities in the management of cardiovascular disease among men and women. We sought to evaluate these disparities and their associations with clinical outcomes among patients admitted with acute coronary syndromes to the Veterans Affairs Healthcare System. Methods and Results We identified all patients that were discharged with acute coronary syndromes within the Veterans Affairs Healthcare System from October 1, 2015 to September 30, 2022. Medical and procedural management of patients was subsequently assessed, stratified by sex. In doing so, we identified 76 454 unique admissions (2327 women, 3.04%), which after propensity matching created an analytic cohort composed of 6765 men (74.5%) and 2295 women (25.3%). Women admitted with acute coronary syndromes were younger with fewer cardiovascular comorbidities and a lower prevalence of preexisting prescriptions for cardiovascular medications. Women also had less coronary anatomic complexity compared with men (5 versus 8, standardized mean difference [SMD]=0.40), as calculated by the Veterans Affairs SYNTAX score. After discharge, women were significantly less likely to receive cardiology follow‐up at 30 days (hazard ratio [HR], 0.858 [95% CI, 0.794–0.928]) or 1 year (HR, 0.891 [95% CI, 0.842–0.943]), or receive prescriptions for guideline‐indicated cardiovascular medications. Despite this, 1‐year mortality rates were lower for women compared with men (HR, 0.841 [95% CI, 0.747–0.948]). Conclusions Women are less likely to receive appropriate cardiovascular follow‐up and medication prescriptions after hospitalization for acute coronary syndromes. Despite these differences, the clinical outcomes for women remain comparable. These data suggest an opportunity to improve the posthospitalization management of cardiovascular disease regardless of sex.

BackgroundElectronic medical records (EMRs) offer the promise of computationally identifying sarcoidosis cases. However, the accuracy of identifying these cases in the EMR is unknown.ObjectiveThe aim of this study is to determine the statistical performance of using the International Classification of Diseases (ICD) diagnostic codes to identify patients with sarcoidosis in the EMR.MethodsWe used the ICD diagnostic codes to identify sarcoidosis cases by searching the EMRs of the San Francisco and Palo Alto Veterans Affairs medical centers and randomly selecting 200 patients. To improve the diagnostic accuracy of the computational algorithm in cases where histopathological data are unavailable, we developed an index of suspicion to identify cases with a high index of suspicion for sarcoidosis (confirmed and probable) based on clinical and radiographic features alone using the American Thoracic Society practice guideline. Through medical record review, we determined the positive predictive value (PPV) of diagnosing sarcoidosis by two computational methods: using ICD codes alone and using ICD codes plus the high index of suspicion.ResultsAmong the 200 patients, 158 (79%) had a high index of suspicion for sarcoidosis. Of these 158 patients, 142 (89.9%) had documentation of nonnecrotizing granuloma, confirming biopsy-proven sarcoidosis. The PPV of using ICD codes alone was 79% (95% CI 78.6%-80.5%) for identifying sarcoidosis cases and 71% (95% CI 64.7%-77.3%) for identifying histopathologically confirmed sarcoidosis in the EMRs. The inclusion of the generated high index of suspicion to identify confirmed sarcoidosis cases increased the PPV significantly to 100% (95% CI 96.5%-100%). Histopathology documentation alone was 90% sensitive compared with high index of suspicion.ConclusionsICD codes are reasonable classifiers for identifying sarcoidosis cases within EMRs with a PPV of 79%. Using a computational algorithm to capture index of suspicion data elements could significantly improve the case-identification accuracy.

The United States Department of Veterans Affairs (VA) uses a systematized approach for disseminating evidence-based, trauma-focused psychotherapies for post-traumatic stress disorder (PTSD). Within this approach, veterans with PTSD must often choose between Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), each delivered in their standard protocols. Many veterans have been greatly helped by this approach. Yet limiting trauma-focused therapy to these two options leaves the VA unable to fully address the needs of a variety of veterans. This limitation, among other factors, contributes to the suboptimal attrition rates within the VA. The present review proposes solutions to address treatment barriers that are both practical (such as time and travel constraints) and psychological (such as resistance to trauma exposure). By reducing barriers, attrition may lessen. Proposed countermeasures against practical barriers include intensive protocols, shortened sessions, telehealth, smartphone application delivery, or any combination of these methods. Countermeasures against psychological barriers include alternative evidence-based treatment programs (such as Acceptance and Commitment Therapy), intensive protocols for exposure-based treatments, and the integration of components from complementary treatments to facilitate PE and CPT (such as Motivational Interviewing or family therapy). By further tailoring treatment to veterans’ diverse needs, these additions may reduce attrition in VA services for PTSD.

This article reveals the relevance and possibilities of adopting the best practices of the United States in Ukraine in the process of conceptualizing the model of the state veterans policy's development. It provides historical analysis of the process of conceptualizing the updated models of veterans policy in the United States and Ukraine, with its key milestones highlighted. Major components of the latest model of the veterans policy have been defined, with the process of its development in the United States analyzed. The historical stages of conceptualizing the state veterans policy in the United States and Ukraine have been consistently studied, with milestone historical events and factors that had impact on its development in each of the countries defined. The findings of the research make us conclude that the United States have demonstrated a long-lasting evolutionary process of developing the concept of the latest model of the veterans policy. First of all, this concept offering a wide variety of veterans support programs is comprehensive and integrative; being human-centered, it is focused on the process of adapting former military personnel to civilian life. But in Ukraine, the veterans policy's development started only in the last decade. We make conclusions about the relevance of adopting the essential elements of the concept of the veterans policy's latest model at the state level in Ukraine in the context of the full-scale invasion of the Russian Federation. This makes it necessary to further study in detail the expertise of the United States and carry out comparative historical analysis of the processes of conceptualizing the state veterans policy in Ukraine and the United States in order to identify ways to effectively adapt the American best practices in the process of conceptualizing the veterans policy in Ukraine.

The Veteran Affairs Surgical Quality Improvement Program (VASQIP) and National Surgical Quality Improvement Program (NSQIP) are large databases designed to measure surgical outcomes for their respective populations. We sought to compare surgical outcomes in patients undergoing colectomies at Veterans Affairs (VA) hospitals versus non-VA hospitals. After institutional review baord approval, records for 271,523 colectomies from NSQIP and 11,597 from VASQIP between the years 2015 and 2019 were compiled. Demographics, comorbidity, 30-d mortality, and other outcomes were examined using Chi-squared, analysis of variance, Mann Whitney U, and Fisher's Exact Test within SPSS version 26. VASQIP patients were more likely to be male (94.3% versus 48.4%, P < 0.001) and older (median 63, 52-72 versus 67, 60-72 P < 0.001). Veterans were also more likely to have diabetes (25.3% versus 15.8%, P < 0.001), chronic obstructive pulmonary disease (15.4% versus 5.5%, P < 0.001), and congestive heart failure (17.0% versus 1.3%, P < 0.001). Veterans had slightly better 30-d mortality (2.4% versus 2.8%, P = 0.003), less organ space infections (2.8% versus 5.8%, P < 0.001), or postoperative sepsis (3.4% versus 5.3%). Non-VA patients were more likely to be having emergent surgery (13.4% versus 9.6%, P < 0.001) or undergo a laparoscopic approach (57.9% versus 50.2%, P < 0.001). Non-VA patients had shorter postoperative length of stay (5.99 d versus 7.32 d, P < 0.001) and were less likely to return to the operating room (5.3% versus 8.4%, P < 0.001) Despite increased comorbidity, VA hospitals and hospitals enrolled in NSQIP have managed to achieve markedly similar rates of 30-d mortality following colectomy. Further study is needed to better understand the differences between both the populations and surgical outcomes between VA hospitals and non-VA hospitals. • Despite higher rates of comorbidity, veteran affairs (VA) hospitals perform colectomy with similar unadjusted outcomes. • After controlling for major comorbidities, having a colectomy at a VA hospital confers significant survival advantage when compared with non-VA hospitals. • Implementation of laparoscopy was delayed at VA institutions. [ABSTRACT FROM AUTHOR]

How and where patients with advanced cancer facing limited survival spend their time is critical. Healthcare contact days (days with healthcare contact outside the home) offer a patient-centered and practical measure of how much of a person's life is consumed by healthcare. We retrospectively analyzed contact days among decedent veterans with stage IV gastrointestinal cancer at the Minneapolis Veterans Affairs Healthcare System from 2010 to 2021. Among 468 decedents, the median overall survival was 4 months. Patients spent 1 in 3 days with healthcare contact. Over the course of illness, the percentage of contact days followed a "U-shaped" pattern, with an initial post-diagnosis peak, a lower middle trough, and an eventual rise as patients neared the end-of-life. Contact days varied by clinical factors and by sociodemographics. These data have important implications for improving care delivery, such as through care coordination and communicating expected burdens to and supporting patients and care partners. [ABSTRACT FROM AUTHOR]

Introduction: The need for mental health care continues to outpace available providers in the United States. Clinical pharmacists trained in mental health are an available resource for mental health care delivery. To our knowledge, studies have not compared patient outcomes between pharmacist and psychiatrist medication management clinics. The aim of this study is to assess if a significant difference exists between pharmacist and psychiatrist medication management clinics with regard to escalation of care, evidence‐based medication prescribing, and medication adherence. Methods: This study was a retrospective chart review of patients who received an outpatient prescription from a mental health provider between January 1, 2017 to July 1, 2018 at an urban Veterans Affairs (VA) medical center. The primary outcome was a composite of hospital admissions and emergency department visits due to a psychiatric or substance use condition. Secondary outcomes assessed in this study included treatment aspects related to escalation of care, medication prescribing, and adherence to treatment. Results: In this study, 111 patients were included in the pharmacist group and 110 patients in the psychiatrist group with patients matched based on diagnoses. The primary outcome was similar between groups (p = 0.646). The pharmacist clinic had a significantly higher medication possession ratio (p < 0.00001) and laboratory monitoring (p = 0.0015). The psychiatrist clinic had a significantly higher ratio of clinic appointments attended (p = 0.0025). Discussion: Psychiatric pharmacists may serve as an additional resource to provide evidence‐based medication management and improve medication adherence without the need for escalation of care. Increased utilization of psychiatric pharmacists can help improve access to quality care with the psychiatrist shortage. [ABSTRACT FROM AUTHOR]

Introduction: The Veterans Health Administration (VA) Office of Rural Health (ORH) and Office of Women's Health Services (OWH) in FY21 launched a three-year Enterprise-Wide Initiative (EWI) to expand access to preventive care for rural, women Veterans. Through this program, women's health care coordinators (WHCC) were funded to coordinate mammography, cervical cancer screening and maternity care for women Veterans at selected VA facilities. We conducted a mixed-methods evaluation using the RE-AIM framework to assess the program implementation. Materials and methods: We collected quantitative data from the 14 program facilities on reach (i.e., Veterans served by the program), effectiveness (e.g., cancer screening compliance, communication), adoption, and maintenance of women's health care coordinators (WHCC) in FY2022. Implementation of the program was examined through semi-structured interviews with the facility WHCC funding initiator (e.g., the point of contact at facility who initiated the request for WHCC funding), WHCCs, and providers. Results: Reach. The number of women Veterans and rural women Veterans served by the WHCC program grew (by 50% and 117% respectively). The program demonstrated effectiveness as screening rates increased for cervical and breast cancer screening (+0.9% and +.01%, respectively). Also, maternity care coordination phone encounters with Veterans grew 36%. Adoption: All facilities implemented care coordinators by quarter two of FY22. Implementation. Qualitative findings revealed facilitators and barriers to successful program implementation and care coordination. Maintenance: The EWI facilitated the recruitment and retention of WHCCs at respective VA facilities over time. Implications: In rural areas, WHCCs can play a critical role in increasing Reach and effectiveness. The EWI demonstrated to be a successful care coordination model that can be feasibly Adopted, Implemented, and Maintained at rural VA facilities. [ABSTRACT FROM AUTHOR]

The explosive growth of veterans treatment courts (VTCs) in the United States has raised questions concerning which justice-involved veterans (JIV) are eligible and ultimately selected for participation. For instance, should VTCs be more inclusive in their selection processes, and is it possible to do so within existing court parameters? Using data from 145 interviews of team members working in 20 VTCs across the country, this study explores the perceptions of those personnel on a range of factors impacting eligibility determinations of JIV. These include the decision-making processes of VTC teams, determinations of the nexus between a veteran's military service and their offending behavior, and the capacity of jurisdictions to provide treatment and services to all JIV, either through Veterans Affairs programs or community providers. Findings illustrate the variability of VTCs nationwide and suggest that specific midcourse alterations are necessary to fulfill stated court missions. [ABSTRACT FROM AUTHOR]

This article reveals the relevance and possibilities of adopting the best practices of the United States in Ukraine in the process of conceptualizing the model of the state veterans policy's development. It provides historical analysis of the process of conceptualizing the updated models of veterans policy in the United States and Ukraine, with its key milestones highlighted. Major components of the latest model of the veterans policy have been defined, with the process of its development in the United States analyzed. The historical stages of conceptualizing the state veterans policy in the United States and Ukraine have been consistently studied, with milestone historical events and factors that had impact on its development in each of the countries defined. The findings of the research make us conclude that the United States have demonstrated a long-lasting evolutionary process of developing the concept of the latest model of the veterans policy. First of all, this concept offering a wide variety of veterans support programs is comprehensive and integrative; being human-centered, it is focused on the process of adapting former military personnel to civilian life. But in Ukraine, the veterans policy's development started only in the last decade. We make conclusions about the relevance of adopting the essential elements of the concept of the veterans policy's latest model at the state level in Ukraine in the context of the full-scale invasion of the Russian Federation. This makes it necessary to further study in detail the expertise of the United States and carry out comparative historical analysis of the processes of conceptualizing the state veterans policy in Ukraine and the United States in order to identify ways to effectively adapt the American best practices in the process of conceptualizing the veterans policy in Ukraine. [ABSTRACT FROM AUTHOR]

BackgroundPrevious research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance.MethodsWe performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic.ResultsThe prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs.

In this perspective piece, we summarize the development and implementation of multidisciplinary liver tumor boards across the Veterans Affairs health care system dating back to 2010. Referral to multidisciplinary tumor boards (MDLTB) has been demonstrated to decrease the number of unnecessary invasive procedures, reduce health care costs and maximize patient outcomes. Although the VA is the largest single care provider in the US, there is significant heterogeneity in healthcare delivery. We have shown that receiving care at VA centers with MDLTB is associated with higher odds of receiving active therapy and a 13% reduction in mortality. Access to expert hepatology care appears to be one of the critical benefits of MDLTB resulting in 30% reduction in mortality. Integrated health care systems such as the VA have the unique capability of implementing virtual tumor boards that can easily overcome geographic barriers and standardize care across multiple facilities regardless of their access to hepatology or other disciplines. Significant barriers remain requiring implementation plans. This document serves as a roadmap to establish multidisciplinary tumor boards, including standardization of imaging reports, identifying stake holders who need to be present at tumor board, institution buy-in, and specifics for local, regional and integrated service network tumor boards.

Background and aimsThe optimal time interval for diagnostic colonoscopy completion after an abnormal stool-based colorectal cancer (CRC) screening test is uncertain. We examined the association between time to colonoscopy and CRC outcomes among individuals who underwent diagnostic colonoscopy after abnormal stool-based screening.MethodsWe performed a retrospective cohort study of veterans age 50 to 75 years with an abnormal fecal occult blood test (FOBT) or fecal immunochemical test (FIT) between 1999 and 2010. We used multivariable Cox proportional hazards to generate CRC-specific incidence and mortality hazard ratios (HRs) and 95% confidence intervals (CI) for 3-month colonoscopy intervals, with 1 to 3 months as the reference group. Association of time to colonoscopy with late-stage CRC diagnosis was also examined.ResultsOur cohort included 204,733 patients. Mean age was 61 years (SD 6.9). Compared with patients who received a colonoscopy at 1 to 3 months, there was an increased CRC risk for patients who received a colonoscopy at 13 to 15 months (HR 1.13; 95% CI 1.00-1.27), 16 to 18 months (HR 1.25; 95% CI 1.10-1.43), 19 to 21 months (HR 1.28; 95% CI: 1.11-1.48), and 22 to 24 months (HR 1.26; 95% CI 1.07-1.47). Compared with patients who received a colonoscopy at 1 to 3 months, mortality risk was higher in groups who received a colonoscopy at 19 to 21 months (HR 1.52; 95% CI 1.51-1.99) and 22 to 24 months (HR 1.39; 95% CI 1.03-1.88). Odds for late-stage CRC increased at 16 months.ConclusionsIncreased time to colonoscopy is associated with higher risk of CRC incidence, death, and late-stage CRC after abnormal FIT/FOBT. Interventions to improve CRC outcomes should emphasize diagnostic follow-up within 1 year of an abnormal FIT/FOBT result.

Background and purposeNeutrophil-lymphocyte ratio (NLR) has been associated with overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to assess the utility of NLR as a predictor of lung cancer-specific survival (LCS) and identify an optimal, pretreatment cutoff point in patients with localized NSCLC treated with stereotactic body radiotherapy (SBRT) within the Veterans Affairs' (VA) national database.Materials and methodsIn the VA database, we identified patients with biopsy-proven, clinical stage I NSCLC treated with SBRT between 2006 and 2015. Cutoff points for NLR were calculated using Contal/O'Quigley's and Cox Wald methods. Primary outcomes of OS, LCS, and non-lung cancer survival (NCS) were evaluated in Cox and Fine-Gray models.ResultsIn 389 patients, optimal NLR cutoff was identified as 4.0. In multivariable models, NLR > 4.0 was associated with decreased OS (HR 1.44, p = 0.01) and NCS (HR 1.68, p = 0.01) but not with LCS (HR 1.32, p = 0.09). In a subset analysis of 229 patients with pulmonary function tests, NLR > 4.0 remained associated with worse OS (HR 1.51, p = 0.02) and NCS (HR 2.18, p = 0.01) while the association with LCS decreased further (HR 1.22, p = 0.39).ConclusionNLR was associated with worse OS in patients with localized NSCLC treated with SBRT; however, NLR was only associated with NCS and not with LCS. Pretreatment NLR, with a cutoff of 4.0, offers potential as a marker of competing mortality risk which can aid in risk stratification in this typically frail and comorbid population. Further studies are needed to validate pretreatment NLR as a clinical tool in this setting.

Objective: To understand the association between Veterans' healthcare utilization and intimate partner violence (IPV) use (i.e., perpetration) in order to (1) identify conditions comorbid with IPV use and (2) inform clinical settings to target for IPV use screening, intervention, and provider training. Data Sources and Study Setting: We examined survey data from a national sample of 834 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) Veterans. Study Design: We assessed associations between past‐year IPV use and medical treatment, health issues, and use of Veterans Health Administration (VA) and non‐VA services using chi‐square tests and logistic regression. Data Collection/Extraction Methods: Data were derived from the Department of Defense OEF/OIF/OND Roster. Surveys were sent to all women Veterans and a random sample of men from participating study sites. Principal Findings: Half (49%) of the Veterans who reported utilizing VA healthcare in the past year indicated using IPV. Q values using a 5% false discovery rate indicated that Veterans who used IPV were more likely than Veterans who did not use IPV to have received treatment for post‐traumatic stress disorder (PTSD; 39% vs. 27%), chronic sleep problems (36% vs. 26%), anxiety or depression (44% vs. 36%), severe chronic pain (31% vs. 22%), and stomach or digestive disorders (24% vs. 16%). Veterans who used IPV were also more likely than Veterans who did not use IPV to have received medical treatment in the past year (86% vs. 80%), seen psychiatrists outside VA (39% vs. 20%), and have outpatient healthcare outside VA (49% vs. 41%). IPV use was not related to whether Veterans received care from VA or non‐VA providers. Conclusions: Veterans' IPV use was related to greater utilization of services for mental health, chronic pain, and digestive issues. Future research should examine whether these are risk factors or consequences of IPV use. [ABSTRACT FROM AUTHOR]

We have previously shown that resident autonomy has decreased over time overall for all surgery residents. The purpose of this study is to examine changes in operative autonomy in general surgery residency within each postgraduate year (PGY) level. This is a retrospective analysis of the Veterans Association Surgical Quality Improvement Program database from July 1, 2004 to September 30, 2019. All general surgery, vascular surgery, and thoracic surgery procedures were analyzed and categorized by level of resident supervision as attending primary, attending operating with resident, or resident primary without attending scrubbed. Procedure work portion of relative value unit was used to capture procedure complexity. Changes in resident autonomy over time, procedure complexity, and outcomes were compared among PGY levels 1 to 5. A total of 385,482 cases were analyzed. At each PGY level from 2014 to 2018, the relative decrease in resident primary cases ranged from −37.3% (PGY 4) to −75.5% (PGY 3). Mean work portion of relative value unit saw steady increase with PGY level (8.4 ± 3.5 in PGY 1 to 10.8 ± 5.7 in PGY 5, P < 0.001) and did not show a trend over time. Surgical resident operative autonomy has markedly decreased over time across all PGY levels. This effect is most profound at the PGY 3 level, while more senior residents are affected to a lesser degree. Case complexity show PGY level-appropriate increase in resident autonomous cases. Decrease in resident autonomy over time is not associated with changes in case complexity. [ABSTRACT FROM AUTHOR]

Chaplains frequently serve as first responders for United States military personnel experiencing suicidal thoughts and behaviors. The Chaplains-CARE Program, a self-paced, e-learning course grounded in suicide-focused cognitive behavioral therapy principles, was tailored for United States military chaplains to enhance their suicide intervention skills. A pilot program evaluation gathered 76 Department of Defense (DoD), Veterans Affairs (VA), and international military chaplain learners' responses. Most learners indicated that the course was helpful, easy to use, relevant, applicable, and that they were likely to recommend it to other chaplains. Based on open-ended responses, one-quarter (25.0%) of learners indicated that all content was useful, and over one-quarter (26.3%) of learners highlighted the usefulness of the self-care module. One-third (30.3%) of learners reported the usefulness of the interactive e-learning features, while others (26.3%) highlighted the usefulness of chaplains' role play demonstrations, which portrayed counseling scenarios with service members. Suggested areas of improvement include specific course adaptation for VA chaplains and further incorporation of experiential learning and spiritual care principles. The pilot findings suggest that Chaplains-CARE Online was perceived as a useful suicide intervention training for chaplains. Future training can be enhanced by providing experiential, simulation-based practice of suicide intervention skills. [ABSTRACT FROM AUTHOR]

Introduction: Despite the high prevalence of those with mental illnesses, there is a critical shortage of psychiatric providers in the United States. Psychiatric pharmacists are valuable members of the health care team who meet patient care needs, especially those practicing with prescriptive authority (PA). Methods: A cross-sectional electronic survey was administered to Board Certified Psychiatric Pharmacists (BCPPs) and non-BCPP members of the College of Psychiatric and Neurologic Pharmacists. The objective of this study was to compare demographic and practice characteristics between respondents with and without PA. Results: Of the 334 respondents, 155 (46.4%) reported having PA. Those with PA, including those with Veterans Affairs (VA) affiliated PA, had fewer mean number of years of licensure than those without PA (P =.008 and P =.007, respectively). The majority with PA practiced in outpatient settings (53.5%). Respondents with PA (including those with VA-affiliated PA) were more likely to have their positions funded by practice sites (P

Abstract The COVID‐19 pandemic disrupted prostate‐specific antigen (PSA) screening and prostate biopsy procedures. We sought to determine whether delayed screening and diagnostic workup of prostate cancer (PCa) was associated with increased subsequent rates of incident PCa and advanced PCa and whether the rates differed by race. We analyzed data from the Veterans Health Administration to assess the changes in the rates of PSA screening, prostate biopsy procedure, incident PCa, PCa with high‐grade Gleason score, and incident metastatic prostate cancer (mPCa) before and after January 2020. While the late pandemic mPCa rate among White Veterans was comparable to the pre‐pandemic rate (5.4 pre‐pandemic vs 5.2 late‐pandemic, p = 0.67), we observed a significant increase in incident mPCa cases among Black Veterans in the late pandemic period (8.1 pre‐pandemic vs 11.3 late‐pandemic, p

People living with human immunodeficiency virus (HIV) are at high risk for anal cancer. Anal cancer screenings are recommended annually for US veterans with HIV. Screenings can identify treatable precursor lesions and prevent cancer development. In a previous study, we found screening rate to be only 15%. Semistructured interviews were conducted with Veterans Affairs (VA) providers who treat veterans living with HIV. Participants described their experiences with anal cancer screenings. Researchers developed a codebook based on Theoretical Domains Framework (TDF) and coded data using thematic analysis to identify barriers to anal cancer screenings. Twenty-three interviews were conducted with VA providers representing 10 regions. Barriers identified corresponded with five targetable TDF domains: Knowledge, Skills, Environmental Context/Resources, Professional Roles/Identities, and Social Influence. Many providers lacked knowledge of screening protocols. Knowledgeable providers often lacked needed resources, including swabs, clinic space, reliable pathology, access to high-resolution anoscopy, or leadership support to implement a screening program. Providers mentioned competing priorities in the care of veterans with HIV infection and lack of skilled/trained personnel to perform the tests. It was often unclear which provider specialty should "own" screening responsibilities. Additional factors included patient discomfort with screening exams. Anal cancer screening protocols are recommended but not widely adopted in VA. There is a critical need to address barriers to anal cancer screenings in veterans. The TDF domains identified align with five intervention domains to target, including education, training, resource/environment, delineation of provider roles, and improved counseling efforts. Targeting these barriers may help improve the uptake of anal cancer screenings within VA. [ABSTRACT FROM AUTHOR]

Summary: Background: Many patients receive guideline-discordant inhaler regimens after chronic obstructive pulmonary disease (COPD) hospitalization. Geography and fragmented care across multiple providers likely influence prescription of guideline-discordant inhaler regimens, but these have not been comprehensively studied. We assessed patient-level differences in guideline-discordant inhaler regimens by rurality, drive time to pulmonary specialty care, and fragmented care. Methods: Retrospective cohort analysis using national Veterans Health Administration (VA) data among patients who received primary care and prescriptions from the VA. Patients hospitalized for COPD exacerbation between 2017 and 2020 were assessed for guideline-discordant inhaler regimens in the subsequent 3 months. Guideline-discordant inhaler regimens were defined as short-acting inhaler/s only, inhaled corticosteroid (ICS) monotherapy, long-acting beta-agonist (LABA) monotherapy, ICS + LABA, long-acting muscarinic antagonist (LAMA) monotherapy, or LAMA + ICS. Rural residence and drive time to the closest pulmonary specialty care were obtained from geocoded addresses. Fragmented care was defined as hospitalization outside the VA. We used multivariable logistic regression models to assess associations between rurality, drive time, fragmentated care, and guideline-discordant inhaler regimens. Models were adjusted for age, sex, race/ethnicity, Charlson Comorbidity Index, Area Deprivation Index, and region. Findings: Of 33,785 patients, 16,398 (48.6%) received guideline-discordant inhaler regimens 3 months after hospitalization. Rural residents had higher odds of guideline-discordant inhalers regimens compared to their urban counterparts (adjusted odds ratio [aOR] 1.18 [95% CI: 1.12–1.23]). The odds of receiving guideline-discordant inhaler regimens increased with longer drive time to pulmonary specialty care (aOR 1.38 [95% CI: 1.30–1.46] for drive time >90 min compared to

Introduction: With the increased use of erenumab and other calcitonin gene‐related peptide antagonists for migraine prevention, increased evidence on long‐term efficacy and real‐world effectiveness is needed. Some reports of a wearing‐off effect or waning efficacy over time have been observed with erenumab use. Objective: This study evaluated the change in efficacy of erenumab after initial established benefits for migraine prevention in a veteran population. Methods: This retrospective chart review evaluated patients who were prescribed erenumab for migraine prevention at a Veterans Affairs neurology clinic between June 1, 2018, and May 31, 2021. Patients with an initial 50% or greater reduction in mean monthly headache days (MHDs) by 12 weeks after erenumab 70 mg initiation were then followed forward to determine the change in MHDs until erenumab dose was increased, changed to galcanezumab, or by November 30, 2021, to ensure a minimum 6‐month follow‐up for all patients. Results: Ninety‐three patients were included for analysis. A significant reduction in mean MHDs from 16.1 to 5.7 days was found by 12 weeks after erenumab 70 mg initiation (p < 0.0001). Following this initial response to erenumab, 69% of patients experienced a significant increase in MHDs over an average time of 7.8 months and required a subsequent dose increase to erenumab 140 mg or change to galcanezumab. The remaining 31% of patients continued erenumab 70 mg monthly with a further nonstatistically significant decline in MHDs. Conclusions: A decrease in efficacy with the long‐term use of erenumab was observed for the majority of patients evaluated in this analysis. This suggests that patients with initial benefits on lower dose erenumab should be monitored for change to effectiveness. [ABSTRACT FROM AUTHOR]

The epidemiology of latent tuberculosis and hepatitis B virus (HBV‐LTBI) co‐infection among U.S. populations is not well studied. We aim to evaluate LTBI testing patterns and LTBI prevalence among two large U.S. cohorts of adults with chronic HBV (CHB). Adults with CHB in the Chronic Hepatitis Cohort Study (CHeCS) and Veterans Affairs national cohort were included in the analyses. Prevalence of HBV‐LTBI co‐infection was defined as the number of HBV patients with LTBI divided by the number of HBV patients in a cohort. Multivariable logistic regression evaluated odds of HBV‐LTBI co‐infection among CHB patients who underwent TB testing. Among 6019 CHB patients in the CHeCS cohort (44% female, 47% Asian), 9.1% were tested for TB, among whom 7.7% had HBV‐LTBI co‐infection. Among HBV‐LTBI co‐infected patient, only 16.7% (n = 7) received LTBI treatment, among whom 28.6% (n = 2) developed DILI. Among 12,928 CHB patients in the VA cohort (94% male, 42% African American, 39% non‐Hispanic white), 14.7% were tested for TB, among whom 14.5% had HBV‐LTBI. Among HBV‐LTBI co‐infected patient, 18.6% (n = 51) received LTBI treatment, among whom 3.9% (n = 3) developed DILI. Presence of cirrhosis, race/ethnicity, and country of birth were observed to be associated with odds of HBV‐LTBI co‐infection among CHB patients who received TB testing. In summary, among two large distinct U.S. cohorts of adults with CHB, testing for LTBI was infrequent despite relatively high prevalence of HBV‐LTBI co‐infection. Moreover, low rates of LTBI treatment were observed among those with HBV‐LTBI co‐infection. [ABSTRACT FROM AUTHOR]

Introduction: With improved technology and technique, laparoscopic inguinal hernia repair (LIHR) has become a valid option for repairing both initial and recurrent inguinal hernia. Surgical residents must learn both techniques to prepare for future practice. We examined resident operative autonomy between LIHR and open inguinal hernia repair (OIHR) across the Veterans Affairs (VA) system. Methods: Utilizing the VA Surgical Quality Improvement Program database, we examined inguinal hernia repairs based on the principal procedure code at all teaching VA hospitals from July 2004 to September 2019. All VA cases are coded for level of supervision at the time of surgery: attending primary surgeon (AP); attending scrubbed but resident is a primary surgeon (AR), and resident primary with attending supervising but not scrubbed (RP). Primary outcomes were the proportion of LIHR versus OIHR and resident autonomy over time. Results: A total of 127,497 hernia repair cases were examined (106,892 OIHR and 20,605 LIHR). There was a higher proportion of RP (8.7% vs 2.2%) and lower proportion of AP (23.9% vs 28.4%) within OIHR compared to LIHR (p < 0.001). The overall proportion of LIHR repairs increased from 9 to 28% (p < 0.001). RP cases decreased for LIHR from 9 to 1% and for OIHR from 17 to 4%, while AP cases increased for LIHR from 16 to 42% and for OIHR from 18 to 30% (all p < 0.001). For RP cases, mortality (0 vs 0.2%, p > 0.99) and complication rates (1.1% vs. 1.7%, p = 0.35) were no different. Conclusions: LIHR at VA hospitals has tripled over the past 15 years, now compromising nearly one-third of all inguinal hernia repairs; the majority are initial hernias. Despite this increase, resident autonomy in LIHR cases declined alarmingly. The results demonstrate an urgent need to integrate enhanced minimally invasive training into a general surgery curriculum to prepare residents for future independent practice. [ABSTRACT FROM AUTHOR]

BackgroundIdentification of a safe and effective medical therapy for abdominal aortic aneurysm (AAA) disease remains a significant unmet medical need. Recent small cohort studies indicate that metformin, the world's most commonly prescribed oral hypoglycemic agent, may limit AAA enlargement. We sought to validate these preliminary observations in a larger cohort.MethodsAll patients with asymptomatic AAA disease managed in the Veterans Affairs Health Care System between 2003 and 2013 were identified by International Classification of Diseases, Ninth Revision codes. Those with a concomitant diagnosis of diabetes mellitus who also received two or more abdominal imaging studies (computed tomography, magnetic resonance imaging, or ultrasound) documenting the presence and size of an AAA, separated by at least 1 year, were included for review. Maximal AAA diameters were determined from radiologic reports. Further data acquisition was censored after surgical AAA repair, when performed. Comorbidities, active smoking status, and outpatient medication records (within 6 months of AAA diagnosis) were also queried. Yearly AAA enlargement rates, as a function of metformin treatment status, were compared using two statistical models expressed in millimeters per year: a multivariate linear regression (model 1) and a multivariate mixed-effects model with random intercept and random slope (model 2).ResultsA total of 13,834 patients with 58,833 radiographic records were included in the analysis, with radiology imaging follow-up of 4.2 ± 2.6 years (mean ± standard deviation). The average age of the patients at AAA diagnosis was 69.8 ± 7.8 years, and 39.7% had a metformin prescription within ±6 months of AAA. The mean growth rate for AAAs in the entire cohort was 1.4 ± 2.0 mm/y by model 1 analysis and 1.3 ± 1.6 mm/y by model 2 analysis. The unadjusted mean rate of AAA growth was 1.2 ± 1.9 mm/y for patients prescribed metformin compared with 1.5 ± 2.2 mm/y for those without (P < .001), a 20% decrease. This effect remained significant when adjusted for variables relevant on AAA progression: metformin prescription was associated with a reduction in yearly AAA growth rate of -0.23 mm (95% confidence interval, -0.35 to -0.16; P < .001) by model 1 analysis and 0.20 mm/y (95% confidence interval, -0.26 to -0.14; P < .001) by model 2 analysis. A subset analysis of 7462 patients with baseline AAA size of 35 to 49 mm showed a similar inhibitory effect (1.4 ± 2.0 mm/y to 1.7 ± 2.2 mm/y; P < .001). Patients' factors associated with an increased yearly AAA growth rate were baseline AAA size, metastatic solid tumors, active smoking, chronic obstructive pulmonary disease, and chronic renal disease. Factors associated with decreased yearly AAA growth rates included prescriptions for angiotensin II type 1 receptor blockers or sulfonylureas and the presence of diabetes-related complications.ConclusionsIn a nationwide analysis of diabetic Veterans Affairs patients, prescription for metformin was associated with decreased AAA enlargement. These findings provide further support for the conduct of prospective clinical trials to test the ability of metformin to limit progression of early AAA disease.

Abstract Background Enhanced Recovery Pathways (ERP) have been shown to reduce racial disparities following surgery. The objective of this study is to determine whether ERP implementation mitigates racial disparities at a Veterans Affairs Hospital. Methods A retrospective cohort study was conducted using data obtained from the Veterans Affairs Surgical Quality Improvement Program. All patients undergoing elective colorectal surgery following ERP implementation were included. Current procedural terminology (CPT) codes were used to identify patients who underwent similar procedures prior to ERP implementation. Results Our study included 417 patients (314 pre-ERP vs. 103 ERP), 97.1% of which were male, with an average age of 62.32 (interquartile range (IQR): 25–90). ERP patients overall had a significantly shorter post-operative length of stay (pLOS) vs. pre-ERP patients (median 4 days (IQR: 3–6.5) vs. 6 days (IQR: 4–9) days (p

IntroductionMeasuring long-term housing outcomes is important for evaluating the impacts of services for individuals with homeless experience. However, assessing long-term housing status using traditional methods is challenging. The Veterans Affairs (VA) Electronic Health Record (EHR) provides detailed data for a large population of patients with homeless experiences and contains several indicators of housing instability, including structured data elements (e.g., diagnosis codes) and free-text clinical narratives. However, the validity of each of these data elements for measuring housing stability over time is not well-studied.MethodsWe compared VA EHR indicators of housing instability, including information extracted from clinical notes using natural language processing (NLP), with patient-reported housing outcomes in a cohort of homeless-experienced Veterans.ResultsNLP achieved higher sensitivity and specificity than standard diagnosis codes for detecting episodes of unstable housing. Other structured data elements in the VA EHR showed promising performance, particularly when combined with NLP.DiscussionEvaluation efforts and research studies assessing longitudinal housing outcomes should incorporate multiple data sources of documentation to achieve optimal performance.